Bright Vision of the Future

By Claudia Wallis

A cure for myopia, lasers for cataracts, bifocal contact lenses

In his 1973 film Sleeper, Woody Allen awakens from a deep-freeze snooze and finds himself in the 22nd century, surrounded by doctors. Peering through his glasses, Allen locks eyes with a doctor who is similarly bespectacled. Svyatoslav Fyodorov, an eminent Soviet eye surgeon, saw the film while visiting New York, and was disturbed by this myopic vision of the future: "It's not logical, I thought. So I wondered how we could avoid wearing glasses." That concern led Fyodorov to develop a radical new treatment for nearsightedness called radial keratotomy, or R/K.

In San Francisco last week, the Soviet doctor, now director of the Moscow Research Institute of Eye Microsurgery, reported on his eight years of experience with R/K surgery. More than 19,000 doctors and technicians from 81 countries had gathered at a joint meeting of the International Congress of Ophthalmology and the American Academy of Ophthalmology (A.A.O.) to hear about Fyodorov's controversial technique and scores of other important innovations in eye care.

The presentation on R/K by the gregarious Fyodorov was eagerly anticipated, especially by those U.S. doctors who practice his technique in the face of skepticism from their colleagues. The procedure takes only 15 minutes. First, the patient's eyes are anesthetized with eyedrops. Next, the cornea, the clear outermost portion of the eye, is marked with six to 16 lines radiating outward from the pupil, like spokes of a wheel. Finally, careful incisions are made along each line, altering the shape of the cornea and changing the spot at which light is focused inside the eye. In nearsightedness, light is focused in front of the retina instead of on it. An R/K corrects this condition by flattening the cornea so it bends light in such a way that images are more properly focused on or near the retina.

As his audience of 500 specialists listened closely, Fyodorov, speaking in a thick Russian accent, described how his clinic does 20 to 25 operations a day. Fyodorov has performed more than 3,000. In 96% of his patients with moderate myopia, Fyodorov claimed to have improved vision to somewhere between 20/15 and 20/40, obviating the need for glasses. In patients with more severe myopia, he reported an Fyodorov 84% success rate. The surgeon declared that he had never lost an eye and had encountered complications in only three cases (two patients with excessive scarring and one with infection).

In 1976, Dr. Leo Bores, a Phoenix eye surgeon, traveled to Moscow to learn the technique. Some 400 U.S. doctors, mostly in private practice, have since been trained in R/K in two-day courses here and abroad. American surgeons have performed the procedure more than 20,000 times, charging between $1,000 and $2,000. Complications have been reported in only three U.S. cases.

Nonetheless, the A.A.O. has expressed fears about the "safety and efficacy" of R/K, much to the annoyance of Fyodorov, who says, "They are afraid of new technology." Bores attributes the resistance to a bias against new procedures espoused by doctors in private practice, as opposed to those "in the hallowed halls of academe." Among the A.A.O.'s concerns about R/K is the fact that results can vary widely from surgeon to surgeon. In addition, little is known about the long-term impact of R/K: patients may ultimately be high-risk candidates for cataracts or other problems. "R/K decreases the amount of nearsightedness in virtually every case," concedes Dr. George Waring of Emory University, "but the decrease is not predictable." Waring, who chairs a five-year study on 500 R/K patients for the National Eye Institute, has found that the procedure is "pretty safe" if done by a competent surgeon. But until more infomation is available, Waring, who is nearsighted, will wear contact lenses.

The eye specialists in San Francisco were also intrigued by a new surgical laser called the YAG (for its components of yttrium, aluminum and garnet). Unlike the argon laser, which has been used by eye surgeons for nearly two decades, the YAG does not produce its effect by burning. Instead, it concentrates light energy into very short, intense pulses that create tiny, 1/10-mm cuts. "It causes a very small explosion," explains French Surgeon Daniele Aron-Rosa, who, along with Swiss Surgeon Franz Fankhauser, is credited with inventing YAG surgery.

Because of its supreme accuracy and safety, the YAG can be applied where an ordinary laser cannot. In Europe, it has been used to treat more than 8,000 patients. The technique was introduced in the U.S. earlier this year, and 800 patients have been treated. While the YAG does not replace traditional cataract surgery to remove a clouded lens, it can be used as a first step to sever the membrane that encloses the lens. The YAG is also valuable in postsurgical followup. In as many as 20% of cataract patients, a second operation is needed to cut away eye membranes that become opaque after the lens has been removed. The YAG can instantly rupture these membranes in an outpatient procedure that replaces four hours of surgery.

"Patients view the YAG as a kind of miracle," says Dr. Stephen Trokel of New York City's Presbyterian Hospital, one of about a dozen U.S. medical centers equipped with the $100,000 machine. Indeed, Florence Clemens, 74, one of Trokel's postcataract patients, reports that although no anesthetic was used, "there was no pain, just the sensation of a very bright, multicolored light." Best of all, when the $900 procedure was over, Clemens could "go right home and start dinner."

The conference offered other glimpses of ocular miracles on the horizon. Among them: "synthetic corneas," tinted plastic inserts that protect the glare-sensitive eyes of albinos; and soft contact lenses that prevent blindness in newborns who have undergone cataract surgery. Contact lenses that can be worn continuously for 100 days are already available to correct myopia and for use after cataract surgery. Soon good bifocal and astigmatic versions will be on the market. Experts say that the day is not far off when a person will buy a six-pack of disposable lenses each year, wear them for two months, throw them away and pop in the next pair. One thing seems increasingly likely: if Woody Allen were to wake up in 2182, he would be the only one wearing glasses.

--By Claudia Wallis. Reported by Dick Thompson/San Francisco

With reporting by Dick Thompson

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